Presented by Presented by Liliana Cohen, MD, FACCLiliana Cohen, MD, FACC

Women and Heart Disease: Women and Heart Disease: New Concepts in Prevention New Concepts in Prevention

and Managementand Management

What is Cardiovascular What is Cardiovascular Disease? Disease?

Cardiovascular disease (or CVD) includes Cardiovascular disease (or CVD) includes heart and blood vessel diseases heart and blood vessel diseases —— diseases that affect the circulatory system diseases that affect the circulatory system

ExamplesExamples

• Coronary heart disease (heart attack)Coronary heart disease (heart attack)

• Cerebrovascular disease (stroke and TIA)Cerebrovascular disease (stroke and TIA)

• High blood pressureHigh blood pressure

• Congestive heart failureCongestive heart failure

• Congenital cardiovascular defectsCongenital cardiovascular defects

• Peripheral vascular diseasePeripheral vascular disease

Blockage of the heart arteries by plaque can cause a Blockage of the heart arteries by plaque can cause a heart attack (myocardial infarction) or a fatal rhythm heart attack (myocardial infarction) or a fatal rhythm

disturbance (cardiac arrest)disturbance (cardiac arrest)

Cardiovascular disease is the leading Cardiovascular disease is the leading cause of death for cause of death for bothboth men and men and

women in the U.S.women in the U.S.

The MythThe Myth

The myth that heart disease is a “man’s disease” The myth that heart disease is a “man’s disease” has been debunked has been debunked

The rate of public awareness of CVD as the The rate of public awareness of CVD as the leading cause of death among U.S. women has leading cause of death among U.S. women has increased from 30% in 1997 to 54% in 2009increased from 30% in 1997 to 54% in 2009

The death rate from coronary artery disease in The death rate from coronary artery disease in females in 2007 had decreased to 1/3 of what it females in 2007 had decreased to 1/3 of what it was in 1980was in 1980

Deaths due to CVD* (United States: 1900–2007)Deaths due to CVD* (United States: 1900–2007)

Source: NHLBI from NCHS reports. * - Source: NHLBI from NCHS reports. * - CVD does not include CVD does not include congenital. congenital.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

CVD and other major causes of death for all males and CVD and other major causes of death for all males and females (United States: 2007). females (United States: 2007).

Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

Prevalence of CVD in adults ≥20 years of age by age and Prevalence of CVD in adults ≥20 years of age by age and sex (NHANES: 2005–2008).sex (NHANES: 2005–2008).

Source: NCHS and NHLBI. These data include CHD, HF, stroke, and hypertension.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

PrevalencePrevalence

Greater than 1 in 3 Americans have one or more Greater than 1 in 3 Americans have one or more types of cardiovascular diseasetypes of cardiovascular disease

Cardiovascular disease still causes approximately Cardiovascular disease still causes approximately one death per minute among women in the one death per minute among women in the United StatesUnited States

Roger et al. 123 (4): e18. (2011)

The Need for PreventionThe Need for Prevention in in Women Women

Over 10,000 US women younger than 45 sustain Over 10,000 US women younger than 45 sustain a heart attack each yeara heart attack each year

The priority for coronary prevention is The priority for coronary prevention is substantial for women of all agessubstantial for women of all ages

Mortality associated with acute MI among Mortality associated with acute MI among women younger than 65 y/o is almost twice that women younger than 65 y/o is almost twice that of menof men

Women Women AREARE Different Than Men Different Than Men

Women are more likely to be olderWomen are more likely to be older Women are more likely to have high blood Women are more likely to have high blood

pressure, diabetes, high cholesterol and heart pressure, diabetes, high cholesterol and heart failurefailure

Women are less likely to be smokersWomen are less likely to be smokers

Symptoms of Heart Disease…Symptoms of Heart Disease…

For both genders, chest pressure/pain is the For both genders, chest pressure/pain is the most common symptom of heart diseasemost common symptom of heart disease

Women May Experience Different Women May Experience Different Symptoms Than MenSymptoms Than Men

Women are more likely to experience:Women are more likely to experience: Neck and shoulder painNeck and shoulder pain Abdominal painAbdominal pain NauseaNausea FatigueFatigue Shortness of breathShortness of breath

Women are more likely to experience silent heart Women are more likely to experience silent heart attacksattacks

Risk FactorsRisk Factors Age Age Family History of Early Heart DiseaseFamily History of Early Heart Disease SmokingSmoking High Blood PressureHigh Blood Pressure High Blood CholesterolHigh Blood Cholesterol DiabetesDiabetes Physical InactivityPhysical Inactivity Being Overweight or ObeseBeing Overweight or Obese

A fat-like substance in the bloodA fat-like substance in the blood Made in the liver and comes Made in the liver and comes

from some foods we eatfrom some foods we eat Too much cholesterol Too much cholesterol

can build up in arteries over timecan build up in arteries over time Can cause heart attacks and strokesCan cause heart attacks and strokes

What is cholesterol?What is cholesterol?

Normal Artery

Clogged Artery Cholesterol

Types of CholesterolTypes of Cholesterol

LDL- Low density LipoproteinLDL- Low density Lipoprotein ““bad” cholesterolbad” cholesterol Contributes to AtherosclerosisContributes to Atherosclerosis The lower your LDL, the lower your risk of heart The lower your LDL, the lower your risk of heart

attack and strokeattack and stroke

HDL- High density LipoproteinHDL- High density Lipoprotein ““good” cholesterolgood” cholesterol Helps remove cholesterol from the arteriesHelps remove cholesterol from the arteries

The National Cholesterol The National Cholesterol Education Program RecommendsEducation Program Recommends:

Total Cholesterol = Less than 200 mg/dlLDL Cholesterol = Less than 100 mg/dlHDL Cholesterol = Women: Greater than 50 mg/dl

Men: Greater than 40 mg/dlTriglycerides = Less than 150 mg/dl

To determine how your levels affect your risk of heart disease, your doctor will also take into account other risk factors.

Controlling Cholesterol and Controlling Cholesterol and TriglyceridesTriglycerides

Healthy EatingHealthy Eating

Physical ActivityPhysical Activity

Weight LossWeight Loss

MedicationMedication

Eating HealthyEating Healthy

Choose more fruits, vegetables, and whole grain breads, Choose more fruits, vegetables, and whole grain breads, cerealscereals

Choose baked, skinless chicken and fish, and low-fat Choose baked, skinless chicken and fish, and low-fat dairy productsdairy products

Eat less fatEat less fat Saturated fatSaturated fat Trans fatty acidsTrans fatty acids

Eat Fiber Eat Fiber Dried beans, peas, oats, fruits and vegetablesDried beans, peas, oats, fruits and vegetables

Improving FatsImproving Fats

Eat fewer solid fats Eat fewer solid fats ShorteningShortening Stick butter/margarineStick butter/margarine Excess fat on meatsExcess fat on meats

Substitute liquid or soft fats “Heart-Healthy Substitute liquid or soft fats “Heart-Healthy Fats”Fats”

Monounsaturated oilsMonounsaturated oils Olive oil, canola oilOlive oil, canola oil

Improving FatsImproving Fats

Avoid Avoid TransTrans fats fats Trans Trans fatty acids raise LDL and lower HDLfatty acids raise LDL and lower HDL Increase risk of heart disease/stroke/Type II Increase risk of heart disease/stroke/Type II

DiabetesDiabetes Found in fried foods, cookies, Found in fried foods, cookies,

cakes, crackers, snack foodscakes, crackers, snack foods Replace trans fats with Replace trans fats with

mono/polyunsaturated fats (fish, seeds) mono/polyunsaturated fats (fish, seeds)

Limit Dietary CholesterolLimit Dietary Cholesterol

Can raise blood cholesterolCan raise blood cholesterol Limit foods high in cholesterolLimit foods high in cholesterol

Liver, organ meats, egg yolks, Liver, organ meats, egg yolks, full-fat dairy productsfull-fat dairy products

The American Heart Association recommends:The American Heart Association recommends: Less than 300 mg/dayLess than 300 mg/day Less than 200 mg/day (with diabetes or heart disease)Less than 200 mg/day (with diabetes or heart disease)

TriglyceridesTriglycerides

Limit sugar and refined carbohydratesLimit sugar and refined carbohydrates

Limit alcohol consumptionLimit alcohol consumption

Substitute mono/polyunsaturated fats for Substitute mono/polyunsaturated fats for saturated fatssaturated fats

Exercise/ weight lossExercise/ weight loss

Physical ActivityPhysical Activity

Important even as we get older!Important even as we get older! HDL CholesterolHDL Cholesterol

LDL CholesterolLDL Cholesterol

Lower triglyceridesLower triglycerides

30 minutes or more on most days30 minutes or more on most days Moderate intensity (150 minutes/week)Moderate intensity (150 minutes/week) High intensity (75 minutes/week)High intensity (75 minutes/week)

Weight ManagementWeight Management

Weight loss can…Weight loss can… LDLLDL TriglyceridesTriglycerides HDLHDL

Just Just 5 to 10 pounds5 to 10 pounds will help show will help show improvements!!!improvements!!!

High Blood PressureHigh Blood Pressure

Systolic pressure Systolic pressure —— pressure in arteries when the heart pressure in arteries when the heart beatsbeats

Diastolic pressure Diastolic pressure —— pressure when the heart rests pressure when the heart rests between beatsbetween beats

Goal: below 120/80 mm Hg Goal: below 120/80 mm Hg

HypertensionHypertension

65% of all hypertension remains either 65% of all hypertension remains either undetected or inadequately treatedundetected or inadequately treated

People who are normotensive at 55 have People who are normotensive at 55 have a 90% lifetime risk of developing HTNa 90% lifetime risk of developing HTN

Prevalence increases with age and women Prevalence increases with age and women live longer- hypertension is more live longer- hypertension is more common in femalescommon in females

HTN is more common with OCP and HTN is more common with OCP and obesityobesity

Lifestyle Approaches to Lifestyle Approaches to HypertensionHypertension

Source: JNC 7 2004, Sacks 2001

Maintain ideal body weightMaintain ideal body weight Weight loss of as little as 10 lbs reduces blood Weight loss of as little as 10 lbs reduces blood

pressure pressure Heart healthy diet Heart healthy diet

Even without weight loss, a diet rich in fruits, Even without weight loss, a diet rich in fruits, vegetables, and low fat dairy products can help to vegetables, and low fat dairy products can help to reduce blood pressurereduce blood pressure

Sodium restriction to 1500 mg/dSodium restriction to 1500 mg/d Increase physical activity Increase physical activity Limit alcohol to one drink per dayLimit alcohol to one drink per day

Alcohol raises blood pressure Alcohol raises blood pressure One drink = 12 oz beer, 4 oz wine, or 1 oz liquorOne drink = 12 oz beer, 4 oz wine, or 1 oz liquor

What Is Diabetes?What Is Diabetes?

AA progressive disease in which your body doesn’t progressive disease in which your body doesn’t make enough insulin / doesn’t respond properly to itmake enough insulin / doesn’t respond properly to it

Goal: fasting glucose below 100 mg/dlGoal: fasting glucose below 100 mg/dl

Why Is Diabetes Bad?Why Is Diabetes Bad?

At least 65%At least 65% of people with diabetes die of some of people with diabetes die of some form of CVDform of CVD

Diabetes lowers “good” cholesterol, and raises “bad” Diabetes lowers “good” cholesterol, and raises “bad” cholesterol and triglyceride levelscholesterol and triglyceride levels

Many people with diabetes also have high blood Many people with diabetes also have high blood pressure and are overweightpressure and are overweight

Risk Factors: Diabetes Risk Factors: Diabetes

Diabetes increases the risk of CHD 3-7 Diabetes increases the risk of CHD 3-7 times in women versus 2-3 times in mentimes in women versus 2-3 times in men

Diabetic women who smoke have a 84% Diabetic women who smoke have a 84% higher risk of developing stroke than higher risk of developing stroke than nonsmokersnonsmokers

2 of 3 people with diabetes die from 2 of 3 people with diabetes die from CHD or strokeCHD or stroke

SmokingSmoking

Smoking is the single mostSmoking is the single most

preventable cause of death in the USpreventable cause of death in the US Cigarette smoking accounts for nearly 440,000 Cigarette smoking accounts for nearly 440,000 deaths per year in men and womendeaths per year in men and women 18.518.5 percent of American women age 18 percent of American women age 18

and older smoke and older smoke

                

The #1 Preventable RiskThe #1 Preventable Risk Smoking Smoking

50% of heart attacks among women 50% of heart attacks among women are due to smoking. Smokers tend to are due to smoking. Smokers tend to have their first heart attack 10 years have their first heart attack 10 years earlier than nonsmokersearlier than nonsmokers

If you smoke, you are 4-6x’s more If you smoke, you are 4-6x’s more likely to suffer a heart attack and likely to suffer a heart attack and increase your risk of a strokeincrease your risk of a stroke

Women who smoke and take OCP’s Women who smoke and take OCP’s increase their risk of heart disease 30x’sincrease their risk of heart disease 30x’s

Relative Risk of Coronary Events Relative Risk of Coronary Events for Smokers Compared to for Smokers Compared to

Non-SmokersNon-Smokers

3.12

5.48

1

0

1

2

3

4

5

6

Never Smoked 1-14 Cigarettes perday

15 Cigarettes perday

Relative Risk

Source: Adapted from Stampfer 2000

Physical InactivityPhysical Inactivity

Increases heart disease and stroke riskIncreases heart disease and stroke risk 30 minutes or more of activity on most or all days of 30 minutes or more of activity on most or all days of

the week helps reduce risk! the week helps reduce risk! It:It:Controls blood cholesterolControls blood cholesterolControls diabetes and obesityControls diabetes and obesity

Helps lower high blood pressureHelps lower high blood pressure

Body Weight and CHD Mortality Body Weight and CHD Mortality Among WomenAmong Women

5.8

4.6

3.1

1.411

0

1

2

3

4

5

6

19.0-21.9 22.0-24.9 25.0-26.9 27.0-28.9 29.0-31.9 32

BMI

Relative Risk of CHD

Mortality Compared to

BMI<19

P for trend < 0.001

Source: Adapted from Manson 1995

1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009

(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2009

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC

Weight Maintenance/Reduction Weight Maintenance/Reduction GoalsGoals

BMI between 18.5 and 24.9BMI between 18.5 and 24.9 Waist circumference < 35 inches for women, <40 Waist circumference < 35 inches for women, <40

inches for meninches for men Weight loss goalsWeight loss goals

10% of body weight over six months or 1-2 pounds 10% of body weight over six months or 1-2 pounds

weight loss/weekweight loss/week Reduce calories by 500-1,000 per dayReduce calories by 500-1,000 per day

Source: Mosca 2004, ATP III 2002

How To Lower Heart Disease How To Lower Heart Disease RiskRisk

Begin todayBegin today Be physically active—30 minutes of moderate-Be physically active—30 minutes of moderate-

intensity activity on most days of the weekintensity activity on most days of the week Follow a healthy eating planFollow a healthy eating plan

Low in saturated fat, Low in saturated fat, transtrans fat, and cholesterol and fat, and cholesterol and moderate in total fatmoderate in total fat

Limit salt Limit salt If you drink alcoholic beverages, have no If you drink alcoholic beverages, have no

more than one a daymore than one a day

How To Lower Heart Disease How To Lower Heart Disease RiskRisk

Maintain a healthy weightMaintain a healthy weight Balance calories taken in with those used up in Balance calories taken in with those used up in

physical activityphysical activity

Stop smokingStop smoking Get checked for high blood pressureGet checked for high blood pressure Manage diabetesManage diabetes Take medication, if prescribedTake medication, if prescribed

How to SurviveHow to Survive

Call 9-1-1 Call 9-1-1 Emergency medical personnel will begin Emergency medical personnel will begin

treatment at oncetreatment at once Don’t drive yourself to the hospitalDon’t drive yourself to the hospital Uncertainty is normal—don’t be embarrassed by Uncertainty is normal—don’t be embarrassed by

a false alarma false alarm Learn the warning signsLearn the warning signs

Thank you for listening!!!!Thank you for listening!!!!